Improved Cardiorespiratory Fitness With Aerobic Exercise Training in Individuals With Traumatic Brain Injury

Attrition, adherence, and compliance to exercise training interventions in persons with traumatic brain injury: a systematic review of training studies

BACKGROUND

Exercise training (ET) is a promising rehabilitation approach for long-term negative consequences of traumatic brain injury (TBI). However, little is known regarding overall rates of attrition, adherence, and compliance to ET in TBI.

OBJECTIVE

The purpose of this systematic review was to estimate average attrition, adherence, and compliance rates in ET studies in persons with TBI.

METHODS

Databases were searched from inception to April 15, 2024. Two authors independently extracted data related to attrition, adherence, compliance, and possible moderators identified a priori.

RESULTS

The average rate of attrition from 45 studies was 14.4%, although the majority of studies had small sample sizes (i.e. n < 42). Based on hierarchical linear regression, the most influential predictors of attrition were sample size and study design. A minority of studies reported adherence (44.4%) or compliance (22.2%) but those that did reported good average adherence (85.1%) and compliance (77.7%). These studies support the ability of persons with TBI to complete an ET intervention as prescribed.

CONCLUSIONS

Researchers can use this information to ensure adequate power to detect a true effect of ET in persons with TBI. Researchers conducting ET studies in persons with TBI should clearly and thoroughly report data on attrition, adherence, and compliance.

Comparative Efficacy of High-Intensity Training Versus Conventional Training in Individuals With Chronic Traumatic Brain Injury: A Pilot Randomized Controlled Study

Numerous studies have evaluated the efficacy of interventions to improve locomotion after acute-onset brain injury, although most focus on patients with stroke, with less attention toward traumatic brain injury (TBI). For example, a number of studies in patients post-stroke have evaluated the effects of high-intensity training (HIT) attempting to maximize stepping practice, while no studies have attempted this intervention in patients with TBI. The purpose of this blinded-assessor randomized trial was to evaluate the effects of HIT focused on stepping practice versus conventional training on walking and secondary outcomes in individuals with TBI. Using a crossover design, ambulatory participants with TBI >6-months duration performed HIT focused on stepping in variable contexts (overground, treadmill, stairs) or conventional training for up to 15 sessions over five weeks, with interventions alternated >4 weeks later. HIT focused on maximizing stepping practice while trying to achieve higher cardiovascular intensities (>70% heart rate reserve), while conventional training focused on impairment-based and functional exercises with no restrictions on intensities achieved. Greater increases in 6-min walk test and peak treadmill speed during graded exercise testing were observed after HIT versus conventional training, with moderate associations between differences in stepping practice and outcomes. Greater gains were also observed in estimates of aerobic capacity and efficiency after HIT, with additional improvements in selected cognitive assessments. The present study suggests that the amount and intensity of stepping practice may be important determinants of improved locomotor outcomes in patients with chronic TBI, with possible secondary benefits on aerobic capacity/efficiency and cognition. Clinical Trial Registration-URL: https://clinicaltrials.gov/; Unique Identifier: NCT04503473.

Community-based exercise program, self-reported health-related symptoms, and quality of life in persons with traumatic brain injury 45 + years old

BACKGROUND

Individuals with moderate to severe traumatic brain injury (msTBI) have reported a lack of motivation, lack of time, and fatigue as perceived barriers to exercise.

OBJECTIVE

To evaluate the effects of an exercise program on self-reported health-related symptoms and quality of life in persons 45-years and older with msTBI.

METHODS

Post-hoc analysis of a prospective community-based 12-week exercise program of 20 adults, age 45-80 years, with msTBI. Ten were in aerobic exercise training (AET) program and 10 in a stretching and toning (SAT) program. The AET group was instructed to exercise based on their estimated maximal heart rate (HR) for 150 minutes weekly. The SAT group was to stretch for the same target time without significantly increasing HR or level of exertion. Outcome measures were Traumatic Brain Injury Quality of Life (TBI-QOL) for global, cognitive, emotional, and social health, Patient Health Questionnaire-9 (PHQ-9) for depressive symptoms, and Pittsburgh Sleep Quality Index (PSQI) for sleep quality.

RESULTS

AET was associated with improved self-reported cognitive health and sleep compared to SAT. Moderate to large, positive effect sizes were also observed in the AET group in the QOL categories of global, emotional, and social health, and depressive symptoms.

CONCLUSIONS

This study offers preliminary evidence that AET may improve health-related QOL, especially for cognition and sleep, in middle-aged and older adults with msTBI.

Effectiveness of exercise in improving quality of life in patients with traumatic brain injury: A systematic review and meta-analysis

BACKGROUND

Traumatic brain injury (TBI) is a major cause of disability and mortality worldwide. People with TBI exhibit poor quality of life (QOL). Exercise is considered a possible intervention for improving cognitive function and mood, helping improve QOL in patients with TBI. According to our review of the relevant literature, meta-analyses have yet to explore the effect of exercise on QOL in patients with TBI.

OBJECTIVES

To determine by meta-analysis of relevant studies whether physical exercise could promote QOL in patients with TBI.

METHODS

A systematic review and meta-analysis of intervention studies involving physical exercise for improving QOL outcomes in TBI populations were conducted according to the PRISMA guideline. Our inclusion criteria were as follows: being randomized or nonrandomized controlled trials with quantitative designs that included patients diagnosed with TBI.

RESULTS

Thus, six studies met the inclusion criteria. The interventions in four of the six studies had statistically significant effects on QOL improvement. Our meta-analysis revealed a moderate effect size of physical exercise on QOL promotion in patients with TBI.

CONCLUSION

For TBI, exercise seems to improve QOL. More research with long-term follow-up should be conducted to assess the effect of exercise on patients with TBI.

SWOT analysis of a physical activity intervention delivered to outpatient adults with a mild traumatic brain injury

Objectives

Physical activity interventions are effective to reduce the symptoms and recovery time after a mild traumatic brain injury; such interventions are not always embedded in all interdisciplinary outpatient settings. Service providers of a specialized rehabilitation program recognized the need to implement emerging evidence-based approaches to improve physical activity delivery. Understanding the perceptions of managers, clinicians, and users regarding the strengths, weaknesses, opportunities, and threats of the current physical activity intervention delivered to outpatient adults with a mild traumatic brain injury could inform local and widespread intervention development, enhancement, and implementation of evidence-based physical activity interventions.

Methods

This study used a descriptive qualitative design using a strength, weakness, opportunity, and threat analysis framework. Managerial staff (n = 3), clinicians (n = 6), and program users (n = 5) with persisting symptoms following a mild traumatic brain injury from an outpatient specialized public rehabilitation program in Québec (Canada) participated. Individual semi-structured interviews were performed, recorded, transcribed verbatim, and analyzed using a qualitative content analysis approach.

Results

Participants were generally positive about the intervention but expressed that improvement was required. Strengths (n = 15), weaknesses (n = 17), opportunities (n = 12), and threats (n = 6) related to eight overarching categories: physical activity intervention, health-related outcomes, clinical expertise, knowledge translation, communication, user engagement, resources, and accessibility. Category descriptions, convergent and divergent perspectives, and salient quotes of participants are provided.

Conclusions

Participants were generally positive about the intervention (e.g., format) but identified weaknesses (e.g., need for service providers to better describe the physical activity intervention using theoretically driven approaches). Consultations of stakeholders will inform future intervention enhancement efforts and assist in ensuring interventions meet user needs.

Cardiometabolic determinants of cardiorespiratory fitness at rest, during exercise and post-exercise periods

We aimed to assess the relationship between cardiorepiratory fitness (CRF) and cardiometabolic parameters among young Nigerian adults. 100 young adults (50 males, 50 females) aged 20-30 years, selected from College of Health Sciences, Nnamdi Azikiwe University, Nigeria, participated in the study. Subjects’ demographic data and medical information were obtained through the use of structured pre-exercise health and lifestyle screening questionnaire, physical examination and morphometric measurements. Exercise test was carried out using a mechanically braked magnetic ergometer bicycle at an incremental workload of 30 W every 2 min until the subject reached a volitional exhaustion. Blood pressure (BP) and heart rate (HR) were measured at rest, during exercise and at post-exercise periods. Data indicated a significantly (Ρ<0.05) lower resting HR and rate pressure product (RPP), but higher targeted HR reserve, %RPP increase, peak oxygen pulse, cardiac output, exercise duration and work rate compared with the intermediate and unfit groups in both sexes. Age and BMI adjusted correlation test also indicated significant associations between peak oxygen consumption (VO2) and resting HR, resting RPP, targeted HR reserve, oxygen pulse, cardiac output, % RPP increase, actual HR reserve, exercise duration, and work rate. In contrast, resting BP, resting pulse pressure, peak systolic blood pressure (SBP), peak HR, percentage maximum HR, SBP recovery and HR recovery did not correlate with peak VO2. The present findings suggest that a multiple approach involving both metabolic and cardiovascular interventions might be appropriate when implementing strategies to enhance CRF and improve general well-being.

Carotid Arterial Compliance and Aerobic Exercise Training in Chronic Traumatic Brain Injury: A Pilot Study

OBJECTIVE

Decreased carotid arterial compliance (CAC) is associated with cerebral microvascular damage, cerebral blood flow (CBF) dysregulation, and increased risk for stroke and dementia, which are reported to be prevalent after traumatic brain injury (TBI). However, the effect of TBI on CAC has not been reported. The purposes of this pilot study were to (1) compare CAC between participants with chronic traumatic brain injury (cTBI) and age-matched healthy control (HC) subjects and (2) to examine whether CAC changed after 3 months of exercise training in those with cTBI.

SETTING

Community based.

PARTICIPANTS

Nineteen participants with cTBI (6-72 months postinjury) and 19 HC matched for age and sex were tested at baseline. The same cTBI cohort was enrolled in a proof-of-concept randomized controlled exercise training program to investigate the effects of 3 months of aerobic exercise training (AET) or nonaerobic stretching and toning (SAT) on cerebrovascular parameters.

DESIGN

Cross-sectional study and randomized controlled trial.

MAIN MEASURES

CAC was measured by tonometry and ultrasonography at the common carotid artery; CBF was measured by ultrasonography at the bilateral internal carotid and vertebral arteries, and pulsatile CBF was measured by transcranial Doppler ultrasonography at the middle cerebral arteries. Cerebrovascular resistance (CVR) was calculated as mean arterial pressure divided by total CBF.

RESULTS

Relative to HC, the participants with cTBI had lower CAC (0.10 ± 0.03 vs 0.12 ± 0.03 mm 2 /mm Hg, P = .046) and higher CVR (0.17 ± 0.03 vs 0.15 ± 0.03 mm Hg/mL/min, P = .028). CAC tended to increase after AET compared with SAT ( P = .080). Increases in CAC were associated with decreased pulsatile CBF ( r = -0.689, P = .003).

CONCLUSION

These findings suggest that the individuals with cTBI have decreased CAC, which may potentially be improved by AET.

Feasibility of virtual reality and treadmill training in traumatic brain injury: a randomized controlled pilot trial

OBJECTIVE

To evaluate the safety and efficacy of treadmill training with virtual reality compared to treadmill training alone and standard of care balance and mobility treatment in chronic traumatic brain injury (TBI).

PARTICIPANTS AND DESIGN

Thirty-one individuals with chronic TBI with self-reported and objective balance deficits participated in a 4-week 12 session intervention of treadmill training with virtual reality, treadmill training alone, or standard of care overground therapy.

OUTCOME MEASURES

Primary measures included recruitment and enrollment rates, retention, tolerance to intervention, completeness of outcome measures, and adverse events. Secondary measures included the Community Balance and Mobility Scale, 10 Meter Walk Test, 6 Minute Walk Test, and Timed Up and Go.

RESULTS

No serious adverse events were reported. All participants completed all training sessions and assessments at all time points. Recruitment, enrollment, and retention rates were high. All groups showed a trend toward improvement in all balance and mobility measures following treatment.

CONCLUSION

Virtual reality and treadmill training are safe and feasibile for individuals with TBI. Participants show improvements on balance and mobility measures following a 4-week intervention. Future research is needed to evaluate the efficacy of this intervention compared to other modes of balance and mobility training.

A Remotely Delivered Progressive Walking Intervention for Adults With Persistent Symptoms of a Mild Traumatic Brain Injury: Feasibility and Exploration of Its Impact

Introduction

Persistent post-concussion symptoms following a mild traumatic brain injury (mTBI) can impact function and participation of adults. Physical activity is recommended to reduce symptoms and foster return to normal activities. Adults with a mTBI may have personal factors or experience accessibility issues restricting physical activity. Walking is a physical activity accessible to most that could be delivered remotely.

Objectives

Determine the feasibility, safety, and acceptability of a remotely delivered progressive walking intervention designed for adults with persistent mTBI symptoms and explore its effects on health-related outcomes.

Methodology

This feasibility study using a single-group pre-post mixed methods convergent parallel design was conducted remotely. Adults aged 18–65 years with a mTBI reporting persistent symptoms for ≥3 months were recruited. The 8-week remote progressive walking intervention aimed to increase the weekly number of steps walked by 40% based on a 1-week baseline measured by a Fitbit Inspire 2 activity monitor. Feasibility measures were about the intervention, its remote delivery, safety, and acceptability. Health-related outcomes were post-concussion symptoms, kinesiophobia, mood, sleep, fatigue, and quality of life. Semi-structured exit interviews were recorded and transcribed verbatim. Quantitative and qualitative data were analyzed separately, and results merged, compared, and contrasted. Descriptive statistics and paired samples t-tests were used. The qualitative analyses followed an iterative content analysis approach using reflexivity and triangulation of sources.

Results

Twenty adults (16 women) aged 42.5 ± 11.51 years with persisting symptoms for 9.25 ± 6.43 months participated, adhered to 94.38% of sessions, completed the intervention, and found it to be feasible, safe and acceptable. Participants increased weekly total number of steps walked (change = 14,886 ± 18,283; t = 3.55, p = 0.002). Severity of post-concussion symptoms (change = −6.42 ± 10.69; t = −2.62, p = 0.018), kinesiophobia (change = −5 ± 6.86; t = 3.18, p = 0.005), anxiety (change = −1.53 ± 3.01; t = −2.21, p = 0.04), and fatigue (change = −10.21 ± 10.20; t = −4.37, p < 0.001) were reduced, whilst quality of life improved (change = 10.58 ± 13.35; t = 3.46, p = 0.003). Participants' perceptions corroborate most quantitative results; they felt improved self-efficacy about physical activity and provided five key recommendations.

Discussion

This study demonstrates the feasibility, safety, and acceptability of the remote 8-week progressive walking intervention, a promising approach to reduce persisting symptoms, improve physical activity level health-related outcomes and quality of life of adults with persistent post-concussion symptoms following a mTBI.

Fatigue After Traumatic Brain Injury: A Systematic Review

OBJECTIVE

To provide a systematic review of published interventions for posttraumatic brain injury fatigue (PTBIF).

METHODS

PubMed and OneSearch were systematically searched for PTBIF interventions published between January 1, 1989, and March 31, 2019. Search results were evaluated for inclusion based on an abstract and full-text review. Inclusion criteria were (1) an investigation of an intervention, (2) participant sample including individuals with traumatic brain injury (TBI), (3) report of fatigue outcome data among individuals with TBI, and (4) articles available in English, Spanish, French, German, Afrikaans, or Dutch. A risk of bias assessment was conducted on all included publications.

RESULTS

The search resulted in 2343 publications, with 37 meeting inclusion criteria for this review. Categories of PTBIF interventions were pharmacological ( n = 13), psychological ( n = 9), exercise-based ( n = 4), complementary alternative medicine ( n = 5), electrotherapeutic ( n = 3), and multimodal ( n = 3). Only methylphenidate, modafinil, and cognitive behavioral therapy interventions included multiple cohorts. Pharmacological and psychological interventions represented the groups with the lowest risk of bias.

CONCLUSIONS

This review includes 37 studies, with 21 studies published after 2014. Methylphenidate and melatonin were the only pharmacological agents found to reduce fatigue in randomized controlled trials. Creatine given to children prospectively at onset of injury reduced fatigue at follow-up. Walking and water aerobics were effective exercise interventions in isolated randomized controlled studies. One multimodal study of children after concussion was more effective at reducing fatigue and postconcussion symptoms than community standard of care. Other interventions had equivocal results. Overall, more work remains to understand and develop treatments for PTBIF.

Corticomuscular coherence is reduced in relation to dorsiflexion fatigability to the same extent in adults with cerebral palsy as in neurologically intact adults

PURPOSE

Fatigue is frequent in adults with cerebral palsy (CP) and it is unclear whether this is due to altered corticospinal drive. We aimed to compare changes in corticospinal drive following sustained muscle contractions in adults with CP and neurologically intact (NI) adults.

METHODS

Fourteen adults with CP [age 37.6 (10.1), seven females, GMFCS levels I-II] and ten NI adults [age 35.4 (10.3), 6 females] performed 1-min static dorsiflexion at 30% of maximal voluntary contraction (MVC) before and after a submaximal contraction at 60% MVC. Electroencephalography (EEG) and electromyography (EMG) from the anterior tibial muscle were analyzed to quantify the coupling, expressed by corticomuscular coherence (CMC).

RESULTS

Adults with CP had lower MVCs but similar time to exhaustion during the relative load of the fatigability trial. Both groups exhibited fatigability-related changes in EMG median frequency and EMG amplitude. The CP group showed lower beta band (16-35 Hz) CMC before fatigability, but both groups decreased beta band CMC following fatigability. There was a linear correlation between decrease of beta band CMC and fatigability-related increase in EMG.

CONCLUSION

Fatigability following static contraction until failure was related to decreased beta band CMC in both NI adults and adults with CP. Our findings indicate that compensatory mechanisms to fatigability are present in both groups, and that fatigability affects the corticospinal drive in the same way. We suggest that the perceived physical fatigue in CP is related to the high relative load of activities of daily living rather than any particular physiological mechanism.

Early Intensified Rehabilitation Training with Hyperbaric Oxygen Therapy Improves Functional Disorders and Prognosis of Patients with Traumatic Brain Injury

Objective: Traumatic brain injury (TBI) is a global public health problem. Hyperbaric oxygen (HBO) therapy may be beneficial for TBI because it improves cerebral blood flow into tissues exhibiting low blood flow. This was done to observe the clinical therapeutic effect of different intensities of rehabilitation training and HBO therapy in early stages of TBI. Approach: In this multicenter, randomized, stratified case-controlled prospective clinical trial, we selected 158 patients with moderate-severe TBI and assigned them into (1) a control group receiving routine once-daily (1/d) rehabilitation training without HBO, (2) study group A receiving routine 1/d rehabilitation training with HBO, (3) study group B receiving twice-daily (2/d) intensified rehabilitation training with HBO, and (4) study group C receiving 2/d intensified rehabilitation training without HBO, all for 3 months. The cognitive ability, activities of daily life (ADL), and movement ability were assessed before and after training with the Fugl-Meyer Assessment (FMA), Functional Independence Measure (FIM), Modified Barthel Index (MBI), and Mini-Mental State Examination (MMSE). Results: FIM, FMA, MBI, and MMSE scores were improved significantly after 1-, 2-, and 3-month rehabilitation training in all TBI patients (p < 0.01), and this improvement was especially remarkable in patients who received 2/d intensified rehabilitation training with HBO (p < 0.01). Innovation: With extensive and intensive research on TBI rehabilitation, it was proved that TBI rehabilitation intervention should be initiated as early as possible. Conclusion: Early intensified rehabilitation training in combination with HBO is more beneficial to the recovery of cognitive, ADL, and movement abilities of TBI patients.

Physical Activity Interventions for Individuals With a Mild Traumatic Brain Injury:: A Scoping Review

OBJECTIVE

To document the characteristics, measured outcomes, and effectiveness of physical activity (PA) interventions designed to improve health-related outcomes in individuals with a mild traumatic brain injury (mTBI) to assist in rehabilitation quality improvement efforts of a TBI rehabilitation program.

METHODS

A scoping review following a 6-step iterative framework search across 5 databases (MEDLINE, CINAHL, PsycINFO, SPORTDiscuss, and EMBASE) and the gray literature (Google) was performed. Selected PA interventions were designed for individuals of all ages and any mechanism of injury (eg, sports-related and falls). Data were charted, collated, and summarized according to the Consensus on Exercise Reporting Template checklist and domains of the International Classification of Functioning, Disability and Health. Involvement of clinical experts ensured tailoring of the knowledge synthesis to meet clinical needs.

RESULTS

Thirty-five articles and 14 gray literature records were retained. Five types of PA interventions were identified with the majority being multimodal. Reporting of PA intervention characteristics was highly variable across studies; many details necessary for intervention replication are missing. Study outcomes focused primarily on improving body functions and symptoms of mTBI, and less frequently on activities, participation, and health-related quality of life. The methodological quality of studies varies.

CONCLUSIONS

Identified PA intervention types offer various management options for healthcare providers. PA interventions may improve a wide range of health-related outcomes supporting the inclusion of PA in the management of individuals of all ages with mTBI. Higher-quality research and better reporting about intervention characteristics is however needed.

Intensity of usual care physical therapy during inpatient rehabilitation for people with neurologic diagnoses

BACKGROUND

Early, intense rehabilitation is essential to promote recovery after stroke, spinal cord injury (SCI), and traumatic brain injury (TBI). However, intensity of usual care rehabilitation interventions during inpatient rehabilitation are poorly characterized.

OBJECTIVE

To describe the intensity of usual care rehabilitation interventions completed during the subacute phase of recovery from neurologic injury.

DESIGN

Observational.

SETTING

Inpatient rehabilitation facility.

INTERVENTIONS

Twenty-two usual care physical therapy interventions were grouped into six categories: gait (four activities), functional (two), strengthening (four), aerobic (six), balance (four), and wheelchair (two).

PATIENTS

Patients admitted to inpatient rehabilitation with a primary diagnosis of stroke, SCI or TBI within 6 months of injury.

MAIN OUTCOME MEASURE(S)

Cardiovascular intensity (physiological and perceived) was recorded during rehabilitation activity sessions. Physiological intensity was assessed by heart rate reserve (HRR) via a Polar A370 Fitness Watch and characterized as very light (<30%), light (30-39%), moderate (40-59%), vigorous (60-89%), and near maximal (≥90%). Perceived intensity was assessed using the Rating of Perceived Exertion scale.

RESULTS

Patients (stroke n = 16 [number of activity sessions = 388/average session duration = 15.1 min]; SCI n = 15 [299/27.3 min]; TBI n = 15 [340/13.4 min]) participated. For patients with stroke, moderate-to-vigorous HRR was attained between 42% (aerobic exercise) to 55% (wheelchair propulsion) of activity sessions. For patients with SCI, moderate-to-vigorous HRR was attained between 29% (strength training) to 46% (gait training) of activity sessions. For patients with TBI, moderate-to-vigorous HRR was attained between 29% (balance activities) to 47% (gait training) of activity sessions. Associations between HRR and rate of perceived exertion were very weak across stroke (r = 0.12), SCI (r = 0.18), and TBI (r = 0.27).

CONCLUSIONS

Patients with stroke, SCI, and TBI undergoing inpatient rehabilitation achieve moderate-to-vigorous intensity during some usual care activities such as gait training. Patient perception of intensity was dissimilar to physiological response.

A proof-of-concept trial of a community-based aerobic exercise program for individuals with traumatic brain injury

Objective: To assess the feasibility of conducting an aerobic exercise training study in a community setting for individuals with traumatic brain injury (TBI)Methods: This is a prospective, randomized, and controlled study. Nine participants (three moderate-to-severe and six mild TBI) were randomized to a community-based 3-month individualized aerobic exercise training program (AET). Seven participants (four moderate-to-severe, three mild TBI) were randomized to a stretching and toning program (SAT). Cardiorespiratory fitness (CRF) level was assessed with peak oxygen uptake (VO_2peak) testing.Results: After 3 months of training, the AET trended toward improved VO_2peak when compared with the SAT group (8% vs - 4%, p = .059) with a large effect size of 1.27. Only 50% of participants in the AET group completed more than 70% of the assigned exercise sessions. No adverse events were reported. Both the AET and SAT groups reported small improvements in self-reported mood symptoms, including depression, anxiety, and anger.Conclusions: It is feasible to conduct an exercise training study and improve CRF for persons with TBI in community settings with structured exercise protocols. However, exploring methods to enhance adherence is crucial for future exercise clinical trials to improve brain health in this population.

Physical Activity Intolerance and Cardiorespiratory Dysfunction in Patients with Moderate-to-Severe Traumatic Brain Injury

Moderate-to-severe traumatic brain injury (TBI) is a chronic health condition with multi-systemic effects. Survivors face significant long-term functional limitations, including physical activity intolerance and disordered sleep. Persistent cardiorespiratory dysfunction is a potentially modifiable yet often overlooked major contributor to the alarmingly high long-term morbidity and mortality rates in these patients. This narrative review was developed through systematic and non-systematic searches for research relating cardiorespiratory function to moderate-to-severe TBI. The literature reveals patients who have survived moderate-to-severe TBI have ~ 25-35% reduction in maximal aerobic capacity 6-18 months post-injury, resting pulmonary capacity parameters that are reduced 25-40% for weeks to years post-injury, increased sedentary behavior, and elevated risk of cardiorespiratory-related morbidity and mortality. Synthesis of data from other patient populations reveals that cardiorespiratory dysfunction is likely a consequence of ventilator-induced diaphragmatic dysfunction (VIDD), which is not currently addressed in TBI management. Thus, cardiopulmonary exercise testing should be routinely performed in this patient population and those with cardiorespiratory deficits should be further evaluated for diaphragmatic dysfunction. Lack of targeted treatment for underlying cardiorespiratory dysfunction, including VIDD, likely contributes to physical activity intolerance and poor functional outcomes in these patients. Interventional studies have demonstrated that short-term exercise training programs are effective in patients with moderate-to-severe TBI, though improvement is variable. Inspiratory muscle training is beneficial in other patient populations with diaphragmatic dysfunction, and may be valuable for patients with TBI who have been mechanically ventilated. Thus, clinicians with expertise in cardiorespiratory fitness assessment and exercise training interventions should be included in patient management for individuals with moderate-to-severe TBI.

[Personalized approach to working up an early motor rehabilitation program for children with vertebral column and spinal cord injury, taking into account exercise tolerance]

BACKGROUND

The relevance of rehabilitation of children with vertebral column and spinal cord injury (VCSCI) is due to the steady growth in the number of such patients. The mandatory conditions for early motor rehabilitation are to size efforts, to exclude fatigue and overtraining, and to gradually increase loads. The priority tasks of drawing up an individual motor program are to determine the rehabilitation abilities of a child and his/her willingness to perform the proposed load.

AIM

To investigate whether the motor rehabilitation program can be personalized for children with severe VCSCI on the basis of estimation of exercise tolerance.

METHODS

The investigation enrolled 25 patients with VCSCI (12 people with superior paraparesis or inferior paraplegia and 13 with inferior paraparesis or inferior paraplegia); their mean age was 12.1±5.0 years. An individual active motor rehabilitation program was worked out for all the patients according to the results of exercise tolerance testing. The latter was performed using ergospirometry to determine the maximum oxygen consumption (VO₂ max) and the time to reach the anaerobic threshold.

RESULTS

After a rehabilitation cycle, all the patients showed an increase in VO₂ max and time to reach the anaerobic threshold. The obtained results about the increase in VO₂ max with active exercises and the expansion of the aerobic corridor in both patient groups suggest that the exercise tolerance was enhanced due to increases in muscle strength and total body endurance. By the end of the rehabilitation cycle, all the patients displayed an increase in the motor density of exercises to 29.2±4.3 (64.9%) of the 45 min. Passive load decreased to 15.8±4.3 (35.1%) min.

CONCLUSION

Assessment of the individual capabilities of a patient allows one to personalize the motor rehabilitation program. Ergospirometry is a technique to monitor the adequacy of the proposed program.

Sensory-motor and cardiorespiratory sensory rehabilitation associated with transcranial photobiomodulation in patients with central nervous system injury: Trial protocol for a single-center, randomized, double-blind, and controlled clinical trial

BACKGROUND

Central nervous system diseases such as stroke, spinal cord injury, traumatic brain injury, and multiple sclerosis can be fatal or cause sequelae, affecting sensorimotor and cardiorespiratory systems and quality of life. These subjects present a low response to aerobic and resistance exercise, due to decreased recruitment of muscle fibers and reduction of metabolic capacity. Aerobic exercises bring benefits in terms of fatigue retardation, gait improvement, regulation of the autonomic nervous system, neuroprotection of the brain, stimulation of the production of endogenous neutrotransmitters related to general well-being, and a favoring of neuroplasticity. Photobiomodulation (PBM Therapy) (previously known as low-level laser therapy), and especially transcranial PBM Therapy, has shown benefits in animals and humans such as cognitive improvement, memory, and behavioral improvement, including attenuation of depression and anxiety, and increased cortical oxygenation. The aims of this trial will be to evaluate the parameters related to the function of the musculoskeletal and cardiorespiratory system and the impact of PBM therapy on these parameters, as part of a rehabilitation and training program for people with reduced mobility.

METHODS

This is a randomized, double-blind, placebo-controlled trial with 3 groups: Control, only cardiorespiratory rehabilitation (CCR), CCR with PBM Therapy (CR-PBM), CCR and placebo PBM Therapy (CR-PlaceboPBM). n = 90, 30 per group. PBM Therapy parameters: 810 nm laser, 0.028 cm, 100 mW, 3.5 W/cm, 30 seconds per point, 3 J per point, 107.1 J /cm to 3 electroencephalogram points F7 and F8 and AFz. The trial will be conducted at the University Clinics and the sessions will be 1 hour twice a week for 9 weeks. Baseline, intermediate (4th week), final (9th week), and 2-month follow-up will be performed. Muscular activation, heart rate variability, lung volumes and capacities, fatigability, exercise tolerance, cognition, and quality of life at baseline will be evaluated. Subsequent to baseline evaluations, the PBM Therapy groups will be offered laser therapy (active or inactive); all groups will then receive CCR.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov ID - NCT03751306 (approval date: November 22, 2018).

More Than Just a Game: The Public Health Impact of Sport and Physical Activity for People With Disabilities (The 2017 DeLisa Lecture)

Although people with disabilities make up a large proportion of our global population and are known to be disproportionately impacted by sedentary lifestyles leading to chronic disease, programs promoting physical activity often fail to address their unique needs. Both environmental and attitudinal factors also act as barriers to full participation. In this context, increasing evidence shows the positive impact of physical activity and sport on outcomes related to physical health, mental health, community participation, and, in some cases, neurorecovery for people with disabilities. Thus, participation should be seen not only as a medical intervention but also as a rights-based issue. We, as physiatrists, can be agents of change by promoting concepts of universal design and inclusion in physical activity and sport programs.

Feasibility of Aerobic Exercise in the Subacute Phase of Recovery From Traumatic Brain Injury: A Case Series

BACKGROUND AND PURPOSE

Aerobic exercise is as important for individuals with traumatic brain injury (TBI) as for the general population; however, the approach to aerobic training may require some adaptation. The objective of the trial program was to examine the feasibility of introducing aerobic physical exercise programs into the subacute phase of multidisciplinary rehabilitation from moderate to severe TBI, which includes computerized cognitive training.

CASE DESCRIPTION

Five individuals undergoing inpatient rehabilitation with moderate or severe TBIs who also have concomitant physical injuries. All of these individuals were in the subacute phase of recovery from TBIs.

INTERVENTION

An 8-week progressive aerobic physical exercise program. Participants were monitored to ensure that they could both adhere to and tolerate the exercise program. In addition to the physical exercise, individuals were undergoing their standard rehabilitation procedures that included cognitive training. Neuropsychological testing was performed to gain an understanding of each individual's cognitive function.

OUTCOMES

Participants adhered to both aerobic exercise and cognitive training. Poor correlations were noted between heart rate reserve and ratings of perceived effort. Two minor adverse events were reported.

DISCUSSION

Despite concomitant physical injuries and cognitive impairments, progressive aerobic exercise programs seem feasible and well tolerated in subacute rehabilitation from moderate to severe TBI. Findings highlight the difficulty in measuring exercise intensity in this population.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A235).

Perceived Barriers to Exercise in Adults with Traumatic Brain Injury Vary by Age

Physical activity and exercise are important adjuncts to medical treatment for overall health in individuals with traumatic brain injury (TBI); however, many individuals do not partake in the recommended weekly exercise. The objective of this study was to investigate the barriers to exercise after TBI and determine whether these barriers varied by age. The sample was 172 adults with moderate to severe TBI who completed Barriers to Physical Exercise and Disability (B-PED) survey. Lack of interest, motivation, and energy as well as cost, lack of counseling on exercise by a physician, not having home equipment, and being too lazy were reported as barriers to exercise by all age groups. Those aged 35 to 54-years-old were more likely to report that cost, lack of transportation, having health concerns, not knowing where to exercise, and fear of leaving the home as barriers to exercise than those aged 18 to 34-years-old or 55-years-old and older. Overall, adults with TBI report multiple barriers to exercise, and these barriers vary by age.

Oxygen uptake on-kinetics before and after aerobic exercise training in individuals with traumatic brain injury

Objective: The high prevalence of fatigue among persons with traumatic brain injury (TBI) may be related to poor cardiorespiratory fitness observed in this population. Oxygen uptake on-kinetics is a method of assessing cardiorespiratory fitness and may be used to examine performance fatigability (decline in performance during a given activity) in persons with TBI.Purpose: To examine the effect of aerobic exercise training on oxygen uptake on-kinetics during treadmill walking in individuals with TBI.Methods: Seven ambulatory adults with chronic non-penetrating TBI performed short moderate-intensity (3-6 metabolic equivalents) walking bouts on a treadmill, prior to and following an aerobic exercise training program (clinicaltrials.gov: NCT01294332). The 12-week training program consisted of vigorous-intensity exercise on a treadmill for 30 min, 3 times a week. Breath-by-breath pulmonary gas exchange was measured throughout the bouts, and oxygen uptake on-kinetics described the time taken to achieve a steady-state response.Results: Faster oxygen uptake on-kinetics was observed after exercise training, for both the absolute and relative intensity as pre-training.Conclusions: Faster oxygen uptake on-kinetics following aerobic exercise training suggests an attenuated decline in physical performance during a standardized walking bout and improved performance fatigability in these individuals with TBI.Implications for rehabilitationSevere fatigue is a common complaint among persons with traumatic brain injury (TBI).Oxygen uptake on-kinetics may be used as an objective physiological measure of performance fatigability in persons with TBI.Faster oxygen uptake on-kinetics following aerobic exercise training suggests improved performance fatigability in these individuals with TBI.Aerobic exercise training appeared beneficial for reducing performance fatigability and may be considered as part of the rehabilitative strategy for those living with TBI.

Outcomes following a locomotor training protocol on balance, gait, exercise capacity, and community integration in an individual with a traumatic brain injury: a case report

Background and Purpose: The NeuroRecovery Network (NRN) established a locomotor training protocol that has shown promising results for individuals with spinal cord injury, yet research to date has not determined its feasibility in those with traumatic brain injury (TBI). The purpose of this case report was to determine the feasibility of implementing the NRN protocol in an individual with a TBI. Case Description: The participant was a 38-year-old male, 21 years post-TBI. Twenty-four sessions of the therapy portion of the NRN protocol were provided. Outcome measures included the Berg Balance Scale (BBS), spatial temporal parameters of gait, 6-Minute Walk Test and Community Integration Questionnaire (CIQ). Outcomes: His BBS score improved from 37/56 to 43/56. Left step length improved; although gait speed, cadence, stride length and right step length did not. Observable changes were noted in quality of gait. Six-Minute Walk Distance increased by 47.2 m while CIQ score changes did not exceed the minimal detectable change (MDC) value. Discussion: Use of the NRN protocol may be feasible in individuals with TBI, though 24 sessions may not have been enough to achieve the full potential benefit of this intervention in an individual with a chronic TBI.

Effect of Aerobic Exercise Training on Mood in People With Traumatic Brain Injury: A Pilot Study

BACKGROUND

Exercise training is associated with elevations in mood in patients with various chronic illnesses and disabilities. However, little is known regarding the effect of exercise training on short and long-term mood changes in those with traumatic brain injury (TBI).

OBJECTIVE

The purpose of this study was to examine the time course of mood alterations in response to a vigorous, 12-week aerobic exercise training regimen in ambulatory individuals with chronic TBI (>6 months postinjury).

METHODS

Short and long-term mood changes were measured using the Profile of Mood States-Short Form, before and after specific aerobic exercise bouts performed during the 12-week training regimen.

RESULTS

Ten subjects with nonpenetrating TBI (6.6 ± 6.8 years after injury) completed the training regimen. A significant improvement in overall mood was observed following 12 weeks of aerobic exercise training (P = .04), with moderate to large effect sizes observed for short-term mood improvements following individual bouts of exercise.

CONCLUSIONS

Specific improvements in long-term mood state and short-term mood responses following individual exercise sessions were observed in these individuals with TBI. The largest improvement in overall mood was observed at 12 weeks of exercise training, with improvements emerging as early as 4 weeks into the training regimen.

Aerobic Exercise for Adolescents With Prolonged Symptoms After Mild Traumatic Brain Injury: An Exploratory Randomized Clinical Trial

OBJECTIVE

To describe the methodology and report primary outcomes of an exploratory randomized clinical trial (RCT) of aerobic training for management of prolonged symptoms after a mild traumatic brain injury (mTBI) in adolescents.

SETTING

Outpatient research setting.

PARTICIPANTS

Thirty adolescents between the ages of 12 and 17 years who sustained a mTBI and had between 4 and 16 weeks of persistent symptoms.

DESIGN

Partially blinded, pilot RCT of subsymptom exacerbation aerobic training compared with a full-body stretching program.

MAIN MEASURES

The primary outcome was postinjury symptom improvement assessed by the adolescent's self-reported Post-Concussion Symptom Inventory (PCSI) repeated for at least 6 weeks of the intervention. Parent-reported PCSI and adherence are also described.

RESULTS

Twenty-two percent of eligible participants enrolled in the trial. Repeated-measures analysis of variance via mixed-models analysis demonstrated a significant group × time interaction with self-reported PCSI ratings, indicating a greater rate of improvement in the subsymptom exacerbation aerobic training group than in the full-body stretching group (F = 4.11, P = .044). Adherence to the home exercise programs was lower in the subsymptom exacerbation aerobic training group compared with the full-body stretching group (mean [SD] times per week = 4.42 [1.95] vs 5.85 [1.37], P < .0001) over the duration of the study.

CONCLUSION

Findings from this exploratory RCT suggest subsymptom exacerbation aerobic training is potentially beneficial for adolescents with persistent symptoms after an mTBI. These findings and other recent research support the potential benefit of active rehabilitation programs for adolescents with persistent symptoms after an mTBI. Larger replication studies are needed to verify findings and improve generalizability. Future work should focus on determining the optimal type, timing, and intensity of active rehabilitation programs and characteristics of individuals most likely to benefit.

Understanding the interplay between mild traumatic brain injury and cognitive fatigue: models and treatments

Nearly 2 million traumatic brain injuries occur annually, most of which are mild (mTBI). One debilitating sequela of mTBI is cognitive fatigue: fatigue following cognitive work. Cognitive fatigue has proven difficult to quantify and study, but this is changing, allowing models to be proposed and tested. Here, we review evidence for four models of cognitive fatigue, and relate them to specific treatments following mTBI. The evidence supports two models: cognitive fatigue results from the increased work/effort required for the brain to process information after trauma-induced damage; and cognitive fatigue results from sleep disturbances. While there are no evidence-based treatments for fatigue after mTBI, some pharmacological and nonpharmacological treatments show promise for treating this debilitating problem. Future work may target the role of genetics, neuroinflammation and the microbiome and their role in complex cognitive responses such as fatigue.

Graded Aerobic Treadmill Testing in Adolescent Traumatic Brain Injury Patients

PURPOSE

To examine the safety and tolerability of clinical graded aerobic treadmill testing in recovering adolescent moderate and severe traumatic brain injury (TBI) patients referred to a multidisciplinary pediatric concussion program.

METHODS

We completed a retrospective case series of two moderate and five severe TBI patients (mean age, 17.3 years) who underwent initial Buffalo Concussion Treadmill Testing at a mean time of 71.6 days (range, 55-87) postinjury.

RESULTS

Six patients completed one graded aerobic treadmill test each and one patient underwent initial and repeat testing. There were no complications. Five initial treadmill tests were completely tolerated and allowed an accurate assessment of exercise tolerance. Two initial tests were terminated early by the treatment team because of neurological and cardiorespiratory limitations. As a result of testing, two patients were cleared for aerobic exercise as tolerated and four patients were treated with individually tailored submaximal aerobic exercise programs resulting in subjective improvement in residual symptoms and/or exercise tolerance. Repeat treadmill testing in one patient performed after 1 month of treatment with submaximal aerobic exercise prescription was suggestive of improved exercise tolerance. One patient was able to tolerate aerobic exercise following surgery for posterior glottic stenosis.

CONCLUSIONS

Preliminary results suggest that graded aerobic treadmill testing is a safe, well tolerated, and clinically useful tool to assess exercise tolerance in appropriately selected adolescent patients with TBI. Future prospective studies are needed to evaluate the effect of tailored submaximal aerobic exercise prescription on exercise tolerance and patient outcomes in recovering adolescent moderate and severe TBI patients.

Prescribing Exercise to Individuals with Disabilities: What Are the Concerns?

It is well known that individuals with disabilities, constituting 15% to 20% of the adult population, experience a disproportionate risk of cardiometabolic disease and are more likely to live sedentary lifestyles when compared with their able-bodied peers. Although many complex factors likely lead to these disparities, targeted exercise programs can be influential in improving the health outcomes of this population. Additionally, it is important to keep several factors in mind when tailoring the exercise prescription for individuals with varied types of disability, given unique factors related to medical history, mobility, and community barriers. By safely engaging individuals with disabilities in exercise programs, clinicians can promote inclusion while making a significant contribution to health outcomes, ensuring that the principles of "Exercise is Medicine" are accessible to individuals of all abilities.

Efficiency of an Active Rehabilitation Intervention in a Slow-to-Recover Paediatric Population following Mild Traumatic Brain Injury: A Pilot Study

Objective. The aim of this study was to identify whether the addition of an individualised Active Rehabilitation Intervention to standard care influences recovery of young patients who are slow-to-recover following a mTBI. Methods. Fifteen participants aged 15 ± 2 years received standard care and an individualised Active Rehabilitation Intervention which included (1) low- to high-intensity aerobic training; (2) sport-specific coordination exercises; and (3) therapeutic balance exercises. The following criteria were used to measure the resolution of signs and symptoms of mTBI: (1) absence of postconcussion symptoms for more than 7 consecutive days; (2) cognitive function corresponding to normative data; and (3) absence of deficits in coordination and balance. Results. The Active Rehabilitation Intervention lasted 49 ± 17 days. The duration of the intervention was correlated with self-reported participation ([Formula: see text]%, r = -0.792, p < 0.001). The average postconcussion symptom inventory (PCSI) score went from a total of 36.85 ± 23.21 points to 4.31 ± 5.04 points after the intervention (Z = -3.18, p = 0.001). Conclusion. A progressive submaximal Active Rehabilitation Intervention may represent an important asset in the recovery of young patients who are slow-to-recover following a mTBI.

The Aetiology of Reduced Cardiorespiratory Fitness Among Adults with Severe Traumatic Brain Injury and the Relationship with Physical Activity: A Narrative Review

Reduced cardiorespiratory fitness or cardiorespiratory deconditioning is a secondary physical impairment commonly reported to affect people after traumatic brain injury (TBI), both in the short- and long-term. Eleven studies have measured peak oxygen uptake${\rm ({\dot V}O}_{{\rm 2peak}} )$to evaluate fitness in this population. The mean (SD)${\rm \dot VO}_{{\rm 2peak}}$from these studies was 27.2 (6.7) mL.kg−1·min−1, which is markedly below the average fitness level of age-matched healthy individuals. The aetiology of cardiorespiratory deconditioning has not been well evaluated among people with TBI; however, studies on prolonged bed rest and studies on the acute consequences of TBI inform our current understanding. The primary aim of this paper is to present a model to describe the physiological factors contributing to the development of cardiorespiratory deconditioning among people with severe TBI. We propose that both central and peripheral factors contribute to reduced fitness, and that these changes occur because of both the initial brain damage and trauma sustained and the prolonged and initially extreme physical inactivity that is commonly experienced after this type of injury. Reduced fitness can significantly affect the ability to return to pre-injury activities. Given that reintegration into the community is a key goal of rehabilitation among people with TBI, interventions that can prevent or reverse reduced fitness need to be implemented.

Improved cognitive performance following aerobic exercise training in people with traumatic brain injury

OBJECTIVE

To examine cognitive function in individuals with traumatic brain injury (TBI) prior to and after participation in an aerobic exercise training program.

DESIGN

Pre-post intervention study.

SETTING

Medical research center.

PARTICIPANTS

Volunteer sample of individuals (N=7) (age, 33.3±7.9y) with chronic nonpenetrating TBI (injury severity: 3=mild, 4=moderate; time since most current injury: 4.0±5.5y) who were ambulatory.

INTERVENTION

Twelve weeks of supervised vigorous aerobic exercise training performed 3 times a week for 30 minutes on a treadmill.

MAIN OUTCOME MEASURES

Cognitive function was assessed using the Trail Making Test Part A (TMT-A), Trail Making Test Part B (TMT-B), and Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Sleep quality and depression were measured with the Pittsburgh Sleep Quality Index (PSQI) and Beck Depression Inventory, version 2 (BDI-II). Indices of cardiorespiratory fitness were used to examine the relation between improvements in cognitive function and cardiorespiratory fitness.

RESULTS

After training, improvements in cognitive function were observed with greater scores on the TMT-A (10.3±6.8; P=.007), TMT-B (9.6±7.0; P=.011), and RBANS total scale (13.3±9.3; P=.009). No changes were observed in measures of the PSQI and BDI-II. The magnitude of cognitive improvements was also strongly related to the gains in cardiorespiratory fitness.

CONCLUSIONS

These findings suggest that vigorous aerobic exercise training may improve specific aspects of cognitive function in individuals with TBI and cardiorespiratory fitness gains may be a determinant of these improvements.